Care TransitionsMORE-PCNCT05245773
MORE-PC: A 30-day Automated SMS Program to Support Post-discharge Transitions of Care
A study testing Automated SMS program to support post-discharge transitions of care in people with Care Transitions, run by University of Pennsylvania at 1 site in United States.
Trial summary
This study will evaluate a 30-day post-discharge intervention using an automated SMS platform to monitor patients and facilitate communication with their primary care practice. The population will be patients who receive care from participating practices and are discharged from an inpatient stay. Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Care Transitions
- What is being tested?
- Automated SMS program to support post-discharge transitions of care
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 5,000 participants
- Where
- 1 siteUnited States
- Study dates
- 29 Mar 2022to 3 Feb 2023
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- The study subjects will be medium to high risk (UPHS risk score 4 and above; an internally developed and validated score assessing a patient's risk for readmission) adult (age ≥ 18) patients of the Penn Primary Care Practices who are discharged home from acute inpatient care in the broad Philadelphia region as identified in HealthShare Exchange (HSX) reports
Who cannot join
- This study will exclude discharges who do not meet criteria for transitional care management. These criteria include discharges after 1) planned chemotherapy admissions; 2) certain scheduled surgeries, including spinal surgery, joint replacements, gastric bypass, transurethral resection of the prostate, gynecologic surgeries, and transplants; 3) obstetrics admissions.
- We will exclude patients from re-enrollment during the study period (once they have been enrolled once, they will not be enrolled again). We will also exclude patients being discharged to home hospice.
Trial locations and contacts
1 site in 1 country.
United States1 site
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania, 19104
About this study
This study will evaluate a 30-day post-discharge intervention using an automated SMS platform to monitor patients and facilitate communication with their primary care practice. The population will be patients who receive care from participating practices and are discharged from an inpatient stay. In addition to the usual phone call from their practice, patients will be randomized to enrollment in the program, wherein they will receive automated SMS messages on a tapering schedule over 30 days.
Read the detailed description
Background:
Current models of post-discharge care management are time and labor intensive, limited in scope, and inconvenient from the patient perspective, particularly when they have a need arise. Automation can significantly scale up patient touches while reserving staff time for concrete patient needs. Text messaging has been shown to enhance patient engagement (as compared to calls) in many settings, possibly due to greater convenience and the potential for asynchronous interaction. We believe using automated text messaging messaging as the foundation of a post-discharge, primary care based care management program can increase patient engagement, allow for earlier and more frequent identification of needs, and improve post-discharge outcomes.
Objective:
To evaluate the impact of a 30-day post-discharge intervention using an automated SMS platform in addition to usual care as compared to usual care alone in a multi-clinic, pragmatic randomized controlled trial on acute care utilization, post-discharge follow-up appointment scheduling and show-rates, overall patient engagement, and overall patient-clinic encounters.
Description of Intervention:
The intervention will consist of automated text messages on a tapering schedule over the course of 30 days post-discharge, with responses escalated back to the practice care management team. After enrollment, patients will receive an initial message asking them if they have a follow up appointment within the next 2 weeks. If they respond no, the practice will be notified to reach out and help them schedule an appointment.
Beginning the day after this introductory message, patients will receive check-in messages on a tapering schedule over the course of 30 days. For the first week they will receive 3 total messages (Monday, Wednesday and Friday); the second week they will receive a total of 2 messages (Tuesday and Thursday). For the last 2 weeks they will receive weekly messages (on Tuesdays). If a patient need is identified, the request will be escalated to the practice (triaged by the care management RN) for a follow up phone call. Patients will be able to reach out at any time throughout the 30 days by sending a message to the same number, and they will be entered into the same pathway. For any escalated need, patients will receive a follow up phone call within 1 business day. Patients who do not respond to 3 consecutive messages will receive an additional check in message ensuring that they still want to be enrolled.
- Conditions
- Care Transitions
- Being tested
- Automated SMS program to support post-discharge transitions of care
- Keywords
- Post-Discharge, Primary Care, Automated Hovering
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Automated SMS program to support post-discharge transitions of careOther
Also called MORE-PC
The intervention will consist of automated text messages on a tapering schedule over the course of 30 days post-discharge, with responses escalated back to the practice care management team. After initial enrollment messages, patients will receive check-in messages on a tapering schedule over the course of 30 days. For the first week they will receive 3 total messages; the second week they will receive a total of 2 messages. For the last 2 weeks they will receive weekly messages. If a patient need is identified, the request will be escalated to the practice (triaged by the care management RN) for a follow up phone call. Patients will be able to reach out at any time by sending a message to the same number, and they will be entered into the same pathway. For any escalated need, patients will receive a follow up phone call from the practice staff.
| Study group | Role | What they receive |
|---|---|---|
| 30-day automated hovering + usual care | Experimental | The intervention arm will get the usual post-discharge call from their practice, typically within 2 business days of discharge. In addition, they will be enrolled in the 30-day automated texting program, wherein they will receive check-in messages on a tapering schedule; they will be free to opt out at any time. They can also message into the platform at any time. Any needs identified through the platform will be escalated to their primary care practice, and they will receive a follow-up phone call from practice staff to address their needs. Receives: Other: Automated SMS program to support post-discharge transitions of care |
| Usual care | No intervention | The control arm will continue to receive the usual post-discharge call from their practice, typically within 2 business days of discharge. |
What is being measured
The primary outcome is the main question the study is designed to answer.
Post-discharge acute care utilization
A composite, binary measure indicating whether a patient visited the ED or was readmitted to inpatient care after discharge from the hospital.
Measured: 30 days post-discharge
Secondary outcomes (7)
Post-discharge days in the hospital
A continuous measure of total days spent in the hospital (in the ED or as an inpatient) after hospital discharge
Measured: 30 days post-discharge
Post-discharge acute care utilization
A composite, binary measure indicating whether a patient visited the ED or was readmitted to inpatient care after discharge from the hospital.
Measured: 7 and 60 days post-discharge
Post-discharge ED visit
A binary measure indicating whether a patient visited the ED after hospital discharge
Measured: 7, 30, and 60 days post-discharge
Readmission
A binary measure indicating whether a patient was readmitted after hospital discharge
Measured: 7, 30, and 60 days post-discharge
Time from discharge to first acute care visit
A continuous measure of the time from discharge to either first ED visit or readmission
Measured: 30 days post-discharge
Post-discharge follow up visit
A binary measure indicating scheduling and completion of a follow up visit with the primary care practice
Measured: 14 days post-discharge
Number of patient-practice interactions
A continuous measure of non-visit interactions between the patient and practice (which will include a) telephone encounters [which are the end point of any needs identified through the automated messaging program] and b) EMR portal messages)
Measured: 30 days post-discharge
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted18 Feb 2022
- Study start29 Mar 2022
- Primary completion4 Jan 2023
- Study completion3 Feb 2023
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (1)Papers the sponsor has linked to this study.
- Other trials for Care TransitionsStudies of the same condition, open and under way.
- More trials run by University of PennsylvaniaThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Model description
- Pragmatic randomized controlled trial with intervention and control arm
- Masking
- None (open label)
- Enrolment
- 5,000 participants (actual)
Sponsor and investigators
- Lead sponsor
- University of Pennsylvania
- Sponsor type
- University, hospital or other
- Collaborators
- UnitedHealth Group
- Responsible party
- Sponsor
- Investigators
- Anna Morgan, MD, MSHP, Principal investigator, University of Pennsylvania
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT05245773
- Sponsor's protocol ID
- 849348
- Acronym
- MORE-PC
- Status last verified
- Feb 2023
- First submitted
- 8 Feb 2022
- Last updated
- 27 Feb 2023
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
Publications
Bressman E, Long JA, Burke RE, Ahn A, Honig K, Zee J, McGlaughlin N, Balachandran M, Asch DA, Morgan AU. Automated Text Message-Based Program and Use of Acute Health Care Resources After Hospital Discharge: A Randomized Clinical Trial. JAMA Netw Open. 2024 Apr 1;7(4):e243701. doi: 10.1001/jamanetworkopen.2024.3701.
PubMed 38564221
Study at a glance
From the registry record, last updated by the sponsor on 27 Feb 2023. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- MORE-PC: A 30-day Automated SMS Program to Support Post-discharge Transitions of Care
- ClinicalTrials.gov ID
- NCT05245773
- Acronym / sponsor ID
- MORE-PC / 849348
- Conditions
- Care Transitions
- Keywords
- Post-Discharge, Primary Care, Automated Hovering
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 5,000 participants (actual)
- Lead sponsor
- University of PennsylvaniaUniversity, hospital or other
- Collaborators
- UnitedHealth Group
- Study start
- 29 Mar 2022 (actual)
- Primary completion
- 4 Jan 2023 (actual)
- Study completion
- 3 Feb 2023 (actual)
- First posted
- 18 Feb 2022 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
This study will evaluate a 30-day post-discharge intervention using an automated SMS platform to monitor patients and facilitate communication with their primary care practice. The population will be patients who receive care from participating practices and are discharged from an inpatient stay. In addition to the usual phone call from their practice, patients will be randomized to enrollment in the program, wherein they will receive automated SMS messages on a tapering schedule over 30 days.
Detailed description
Background:
Current models of post-discharge care management are time and labor intensive, limited in scope, and inconvenient from the patient perspective, particularly when they have a need arise. Automation can significantly scale up patient touches while reserving staff time for concrete patient needs. Text messaging has been shown to enhance patient engagement (as compared to calls) in many settings, possibly due to greater convenience and the potential for asynchronous interaction. We believe using automated text messaging messaging as the foundation of a post-discharge, primary care based care management program can increase patient engagement, allow for earlier and more frequent identification of needs, and improve post-discharge outcomes.
Objective:
To evaluate the impact of a 30-day post-discharge intervention using an automated SMS platform in addition to usual care as compared to usual care alone in a multi-clinic, pragmatic randomized controlled trial on acute care utilization, post-discharge follow-up appointment scheduling and show-rates, overall patient engagement, and overall patient-clinic encounters.
Description of Intervention:
The intervention will consist of automated text messages on a tapering schedule over the course of 30 days post-discharge, with responses escalated back to the practice care management team. After enrollment, patients will receive an initial message asking them if they have a follow up appointment within the next 2 weeks. If they respond no, the practice will be notified to reach out and help them schedule an appointment.
Beginning the day after this introductory message, patients will receive check-in messages on a tapering schedule over the course of 30 days. For the first week they will receive 3 total messages (Monday, Wednesday and Friday); the second week they will receive a total of 2 messages (Tuesday and Thursday). For the last 2 weeks they will receive weekly messages (on Tuesdays). If a patient need is identified, the request will be escalated to the practice (triaged by the care management RN) for a follow up phone call. Patients will be able to reach out at any time throughout the 30 days by sending a message to the same number, and they will be entered into the same pathway. For any escalated need, patients will receive a follow up phone call within 1 business day. Patients who do not respond to 3 consecutive messages will receive an additional check in message ensuring that they still want to be enrolled.
Study design
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Number of arms
- 2
- Model description
- Pragmatic randomized controlled trial with intervention and control arm
| Arm | Type | Receives |
|---|---|---|
| 30-day automated hovering + usual care | Experimental | Other: Automated SMS program to support post-discharge transitions of careThe intervention arm will get the usual post-discharge call from their practice, typically within 2 business days of discharge. In addition, they will be enrolled in the 30-day automated texting program, wherein they will receive check-in messages on a tapering schedule; they will be free to opt out at any time. They can also message into the platform at any time. Any needs identified through the platform will be escalated to their primary care practice, and they will receive a follow-up phone call from practice staff to address their needs. |
| Usual care | No intervention | –The control arm will continue to receive the usual post-discharge call from their practice, typically within 2 business days of discharge. |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (1 listed)
- The study subjects will be medium to high risk (UPHS risk score 4 and above; an internally developed and validated score assessing a patient's risk for readmission) adult (age ≥ 18) patients of the Penn Primary Care Practices who are discharged home from acute inpatient care in the broad Philadelphia region as identified in HealthShare Exchange (HSX) reports
Key exclusion criteria (2 listed)
- This study will exclude discharges who do not meet criteria for transitional care management. These criteria include discharges after 1) planned chemotherapy admissions; 2) certain scheduled surgeries, including spinal surgery, joint replacements, gastric bypass, transurethral resection of the prostate, gynecologic surgeries, and transplants; 3) obstetrics admissions.
- We will exclude patients from re-enrollment during the study period (once they have been enrolled once, they will not be enrolled again). We will also exclude patients being discharged to home hospice.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Automated SMS program to support post-discharge transitions of careAlso: MORE-PCThe intervention will consist of automated text messages on a tapering schedule over the course of 30 days post-discharge, with responses escalated back to the practice care management team. After initial enrollment messages, patients will receive check-in messages on a tapering schedule over the course of 30 days. For the first week they will receive 3 total messages; the second week they will receive a total of 2 messages. For the last 2 weeks they will receive weekly messages. If a patient need is identified, the request will be escalated to the practice (triaged by the care management RN) for a follow up phone call. Patients will be able to reach out at any time by sending a message to the same number, and they will be entered into the same pathway. For any escalated need, patients will receive a follow up phone call from the practice staff. | Other | 30-day automated hovering + usual care |
Primary outcome
Post-discharge acute care utilization
Time frame: 30 days post-discharge
A composite, binary measure indicating whether a patient visited the ED or was readmitted to inpatient care after discharge from the hospital.
7 secondary outcomes
Post-discharge days in the hospital
Time frame: 30 days post-discharge
Post-discharge acute care utilization
Time frame: 7 and 60 days post-discharge
Post-discharge ED visit
Time frame: 7, 30, and 60 days post-discharge
Readmission
Time frame: 7, 30, and 60 days post-discharge
Time from discharge to first acute care visit
Time frame: 30 days post-discharge
Post-discharge follow up visit
Time frame: 14 days post-discharge
Number of patient-practice interactions
Time frame: 30 days post-discharge
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 27 Feb 2023.
- Derived from this study: PubMed 38564221Bressman E, Long JA, Burke RE, Ahn A, Honig K, Zee J, McGlaughlin N, Balachandran M, Asch DA, Morgan AU. Automated Text Message-Based Program and Use of Acute Health Care Resources After Hospital Discharge: A Randomized Clinical Trial. JAMA Netw Open. 2024 Apr 1;7(4):e243701. doi: 10.1001/jamanetworkopen.2024.3701.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Anna Morgan, MD, MSHP principal investigator
University of Pennsylvania
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Automated SMS program to support post-discharge transitions of care in people with Care Transitions, run by University of Pennsylvania at 1 site in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 1 inclusion and 2 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 27 Feb 2023. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Post-discharge acute care utilization (time frame: 30 days post-discharge). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT05245773, which also lists 1 linked publication.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 27 Feb 2023.